Mitral Regurgitation and Mitral Stenosis SEQUALAE of Rheumatic

Mitral Regurgitation and Mitral Stenosis

• SEQUALAE of Rheumatic fever with carditis

• MR • Commonest manifestation of RHD • Incompetence of mitral valve to close leading to backflow of blood

HEMODYNAMICS Leaky mitral valve During sys regurgitation of blood into LA LA pressure inc in systole, dec in diastole Mean LA pr almost N pulmonary PR almost N –no LVF features

• increased volume handled by – LA – LV – Increase in size

MR During sys, blood has 2 exits Systemic circulation Dec ex tolerance/fatigue LA no LVF

• features of LVF appear only if • No / inadequate compensation

• features of LVF appear only if • No / inadequate compensation • Acute • Severe • Failing LV

• with longstanding MR, • Compensation in the form of – Increased size of LA – Dec systemic vasc resis • Increased forward flow • Dec DBP, small water hammer pulse

Clinical features • Fatigue • Exercise intolerance • Examination – Pulse – rapid, high volume – RR – N – in absence of failure – – – PRECORDIUM - Heart size – apex shift PMI L PS heave ? ? epigastric pulsation Thrill + S/D?

• S 1 – – soft N/ Inc – Usually masked by the murmur • S 2 – Split (variable) – Mod/ severe • S 3

• Murmur – Pansystolic – Delayed diastolic – Functional MS – No presystolic accentuation

• ECG – Sinus tachycardia – N axis – LVH + • CXR – – cardiac enlargement – LA enlargement – LVH – pulm v’s prominent • Echo – – Enlarged LA and LV

Differential diagnosis

Treatment • Penicillin prophylaxis • Digitalis • Diuretics • Vasodilators • Operative – Severe MR – after checking for the feasibility of lifelong anticoagulation with the prosthetic valves

Mitral Stenosis • Less common in pediatric age group

• Obstruction to flow of blood

Obstruction at the level of mitral valve Dec flow through the mitral valve LA is thin walled – dec capacity to hypertrophy - compensates by increasing the pressure. No valves between the LA and pulmonary veins Increased pressure transmitted to pulm circ Pulmonary congestion – dyspnea ( MC symptom) Increased pulm a pressure to maintain forward flow from pulm a to L heart PAH RVH

• RVH – – concentric hypertrophy – N sized heart

• With mild MS – N forward flow • With moderate to severe MS – – DEC forward flow – Dec CO – Low vol pulse – Cold extremities with peripheral cyanosis

• 2 unfortunate aspects – Obstruction distal to a thin walled chamber CO cannot increase much with an increased demand – Direct comm between LA and pulmonary vein Increased risk of pulm congestion even with mod MS

• Clinical features • M>F • • • shortness OF breath on exercise At rest (severe) Cough, hemoptysis PND, Acute pulmonary edema Atypical angina

• • • EXAMINATION Low volume pulse Inc RR RVH – engorged neck veins and enlarged liver JVP – inc – Prominent a ? – Prominent v ?

• Precordium – No shift – Tapping apex – PS Heave – Palpable P 2

• Auscultation – S 1 loud – S 2 normally split – Loud P 2 – Opening snap just medial to the apex – Delayed diastolic m with late diastolic accentuation

• ECG – RAD • RVH • P mitrale • CXR – N heart • Pulm congestion • LA enlargement

• Echo

• Severity grading – Inc S 1 – Gap between opening snap and diastolic m – Opening snap and aortic comp of S 2 – Intensity of m? ? ?

• Severty of PAH • Mild PAH – – mild – mod – severe • SEVERE PAH – – Severe MS

• Treatment • Surgical – Closed valvotomy – Balloon valvotomy